Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols
Objective Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our...
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| Veröffentlicht in: | Journal of vascular surgery 2013-06, Vol.57 (6), p.1537-1542 |
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| creator | Bobadilla, Joseph L., MD Wynn, Martha, MD Tefera, Girma, MD Acher, C.W., MD |
| description | Objective Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair. Methods Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure |
| doi_str_mv | 10.1016/j.jvs.2012.12.032 |
| format | Article |
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Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair. Methods Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure <10 mm Hg), endorphin receptor blockade (naloxone infusion), moderate intraoperative hypothermia (<35°C), hypotension avoidance (mean arterial pressure >90 mm Hg), and optimizing cardiac function. Results From 2005 to 2012, 94 consecutive TEVARs were studied. Indications were thoracic aneurysm (n = 48), plaque rupture with or without dissection (n = 23), trauma (n = 15), and other (n = 8). Forty-nine percent were acute, average age was 68.5 years, 60% (n = 56) were male, and the mean follow-up was 12 months. Mean length of aortic coverage was 161 mm, correlating to 59.4% aortic coverage. One patient had delayed paralysis (1.1%; observed/expected ratio, 0.12) and recovered enough to ambulate easily without assistance. Other complications included wound (7.5%), stroke (4.3%), myocardial infarct (4.3%), and renal failure (1.1%). Conclusions Proactive spinal cord protective protocols appear to reduce the incidence of spinal ischemia after TEVAR compared with historical series. This study would suggest that active, as opposed to reactive, approaches to spinal ischemia portend a better long-term outcome. Multimodal protection is essential, especially if long segment coverage is planned.</description><identifier>ISSN: 0741-5214</identifier><identifier>EISSN: 1097-6809</identifier><identifier>DOI: 10.1016/j.jvs.2012.12.032</identifier><identifier>PMID: 23490292</identifier><language>eng</language><publisher>United States: Mosby, Inc</publisher><subject>Aged ; Aortic Aneurysm, Thoracic - surgery ; Clinical Protocols ; Endovascular Procedures - adverse effects ; Female ; Humans ; Incidence ; Male ; Paraplegia - epidemiology ; Paraplegia - etiology ; Paraplegia - prevention & control ; Prospective Studies ; Spinal Cord ; Surgery</subject><ispartof>Journal of vascular surgery, 2013-06, Vol.57 (6), p.1537-1542</ispartof><rights>2013</rights><rights>Published by Mosby, Inc.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c451t-26f50be2ccd3e6ac3ebfca2ff6e76a166951ff057af52e9041cdcff41c12778d3</citedby><cites>FETCH-LOGICAL-c451t-26f50be2ccd3e6ac3ebfca2ff6e76a166951ff057af52e9041cdcff41c12778d3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.sciencedirect.com/science/article/pii/S0741521413000153$$EHTML$$P50$$Gelsevier$$Hfree_for_read</linktohtml><link.rule.ids>314,776,780,3537,27901,27902,65306</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/23490292$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Bobadilla, Joseph L., MD</creatorcontrib><creatorcontrib>Wynn, Martha, MD</creatorcontrib><creatorcontrib>Tefera, Girma, MD</creatorcontrib><creatorcontrib>Acher, C.W., MD</creatorcontrib><title>Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols</title><title>Journal of vascular surgery</title><addtitle>J Vasc Surg</addtitle><description>Objective Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair. Methods Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure <10 mm Hg), endorphin receptor blockade (naloxone infusion), moderate intraoperative hypothermia (<35°C), hypotension avoidance (mean arterial pressure >90 mm Hg), and optimizing cardiac function. Results From 2005 to 2012, 94 consecutive TEVARs were studied. Indications were thoracic aneurysm (n = 48), plaque rupture with or without dissection (n = 23), trauma (n = 15), and other (n = 8). Forty-nine percent were acute, average age was 68.5 years, 60% (n = 56) were male, and the mean follow-up was 12 months. Mean length of aortic coverage was 161 mm, correlating to 59.4% aortic coverage. One patient had delayed paralysis (1.1%; observed/expected ratio, 0.12) and recovered enough to ambulate easily without assistance. Other complications included wound (7.5%), stroke (4.3%), myocardial infarct (4.3%), and renal failure (1.1%). Conclusions Proactive spinal cord protective protocols appear to reduce the incidence of spinal ischemia after TEVAR compared with historical series. This study would suggest that active, as opposed to reactive, approaches to spinal ischemia portend a better long-term outcome. Multimodal protection is essential, especially if long segment coverage is planned.</description><subject>Aged</subject><subject>Aortic Aneurysm, Thoracic - surgery</subject><subject>Clinical Protocols</subject><subject>Endovascular Procedures - adverse effects</subject><subject>Female</subject><subject>Humans</subject><subject>Incidence</subject><subject>Male</subject><subject>Paraplegia - epidemiology</subject><subject>Paraplegia - etiology</subject><subject>Paraplegia - prevention & control</subject><subject>Prospective Studies</subject><subject>Spinal Cord</subject><subject>Surgery</subject><issn>0741-5214</issn><issn>1097-6809</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2013</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kU2LFDEQhoO4uLOrP8CL5Oilx3x00tMIgiyrKwx42N1zyFRX3LSZTpt0zzD_3jSzevAgFFQo3rcq9RQhbzlbc8b1h37dH_JaMC7WJZgUL8iKs7ap9Ia1L8mKNTWvlOD1JbnKuWeMc7VpXpFLIeuWiVasyHEbj9QP4DscAGl0dLTJjgF_eEutmzDR6SkmCx4oDl082AxzsInaAed0ynuacLQ-0aOfnuiYooXJH5Dm0Q82UIipW6oTnsvLM0IM-TW5cDZkfPOcr8njl9uHm7tq-_3rt5vP2wpqxadKaKfYDgVAJ1FbkLhzYIVzGhttudat4s4x1VinBLas5tCBcyVx0TSbTl6T9-e-ZfKvGfNk9j4DhlD-H-dsuFRN3Sqm2yLlZymkmHNCZ8bk9zadDGdm4W16U3ibhbcpUXgXz7vn9vNuj91fxx_ARfDxLMCy5MFjMhn8grrzqTAxXfT_bf_pHzcEP3iw4SeeMPdxToVy2cLkYjD3y8GXe3PJyrGVlL8BzqWpNw</recordid><startdate>20130601</startdate><enddate>20130601</enddate><creator>Bobadilla, Joseph L., MD</creator><creator>Wynn, Martha, MD</creator><creator>Tefera, Girma, MD</creator><creator>Acher, C.W., MD</creator><general>Mosby, Inc</general><scope>6I.</scope><scope>AAFTH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20130601</creationdate><title>Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols</title><author>Bobadilla, Joseph L., MD ; Wynn, Martha, MD ; Tefera, Girma, MD ; Acher, C.W., MD</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c451t-26f50be2ccd3e6ac3ebfca2ff6e76a166951ff057af52e9041cdcff41c12778d3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2013</creationdate><topic>Aged</topic><topic>Aortic Aneurysm, Thoracic - surgery</topic><topic>Clinical Protocols</topic><topic>Endovascular Procedures - adverse effects</topic><topic>Female</topic><topic>Humans</topic><topic>Incidence</topic><topic>Male</topic><topic>Paraplegia - epidemiology</topic><topic>Paraplegia - etiology</topic><topic>Paraplegia - prevention & control</topic><topic>Prospective Studies</topic><topic>Spinal Cord</topic><topic>Surgery</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Bobadilla, Joseph L., MD</creatorcontrib><creatorcontrib>Wynn, Martha, MD</creatorcontrib><creatorcontrib>Tefera, Girma, MD</creatorcontrib><creatorcontrib>Acher, C.W., MD</creatorcontrib><collection>ScienceDirect Open Access Titles</collection><collection>Elsevier:ScienceDirect:Open Access</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of vascular surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Bobadilla, Joseph L., MD</au><au>Wynn, Martha, MD</au><au>Tefera, Girma, MD</au><au>Acher, C.W., MD</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols</atitle><jtitle>Journal of vascular surgery</jtitle><addtitle>J Vasc Surg</addtitle><date>2013-06-01</date><risdate>2013</risdate><volume>57</volume><issue>6</issue><spage>1537</spage><epage>1542</epage><pages>1537-1542</pages><issn>0741-5214</issn><eissn>1097-6809</eissn><abstract>Objective Paraparesis and paraplegia after thoracic endovascular aneurysm repair (TEVAR) is a greatly feared complication. Multiple case series report this risk up to 13% with no, or inconsistent, application of interventions to enhance and protect spinal cord perfusion. In this study, we report our single-institution experience of TEVAR, using the same proactive spinal cord ischemia protection protocol we use for open repair. Methods Endovascular thoracic aortic interventions were performed for both on-label (aneurysm) and off-label (trauma, other) indications. Aortic area covered was recorded as a fraction from the subclavian to celiac origins and reported as a percentage. If debranching was required, measurements were taken from the most distal arch vessel left intact. Intraoperative imaging and postoperative computed tomographic angiogram were used in calculating aortic percent coverage. Outcomes were recorded in a clinical database and analyzed retrospectively. The spinal cord ischemia protection included routine spinal drainage (spinal fluid pressure <10 mm Hg), endorphin receptor blockade (naloxone infusion), moderate intraoperative hypothermia (<35°C), hypotension avoidance (mean arterial pressure >90 mm Hg), and optimizing cardiac function. Results From 2005 to 2012, 94 consecutive TEVARs were studied. Indications were thoracic aneurysm (n = 48), plaque rupture with or without dissection (n = 23), trauma (n = 15), and other (n = 8). Forty-nine percent were acute, average age was 68.5 years, 60% (n = 56) were male, and the mean follow-up was 12 months. Mean length of aortic coverage was 161 mm, correlating to 59.4% aortic coverage. One patient had delayed paralysis (1.1%; observed/expected ratio, 0.12) and recovered enough to ambulate easily without assistance. Other complications included wound (7.5%), stroke (4.3%), myocardial infarct (4.3%), and renal failure (1.1%). Conclusions Proactive spinal cord protective protocols appear to reduce the incidence of spinal ischemia after TEVAR compared with historical series. This study would suggest that active, as opposed to reactive, approaches to spinal ischemia portend a better long-term outcome. Multimodal protection is essential, especially if long segment coverage is planned.</abstract><cop>United States</cop><pub>Mosby, Inc</pub><pmid>23490292</pmid><doi>10.1016/j.jvs.2012.12.032</doi><tpages>6</tpages><oa>free_for_read</oa></addata></record> |
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| subjects | Aged Aortic Aneurysm, Thoracic - surgery Clinical Protocols Endovascular Procedures - adverse effects Female Humans Incidence Male Paraplegia - epidemiology Paraplegia - etiology Paraplegia - prevention & control Prospective Studies Spinal Cord Surgery |
| title | Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols |
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